Treatment of different parts or types of ulcerative colitis:
①Ulcerative proctitis:
A. Initial treatment: lesions are confined to the rectum, and the symptoms are mostly mild, you can use mesalazine (5-amino-salicylic acid) suppositories, 2 to 3 times / d, or cortisone foam 1 to 2 times/d, 1 suppository each time. If suppository intolerance occurs, such as lower abdominal discomfort and rectal irritation, it can be switched to salicylazosulfapyridine (azosulfapyridine) tablets or mesalazine (5-ASA) orally, which is often effective within 2 weeks, and then changed to a maintenance dosage.
B. Maintenance therapy: Mesalazine (5-ASA) suppositories are better used as long-term maintenance therapy, 1 capsule per night, which can reduce recurrence. For those who are intolerant to suppositories, oral maintenance with salicylazosulfapyridine (SASP) or mesalazine (5-ASA) can be used, and the recommended maintenance dosage is salicylazosulfapyridine (SASP ) 2g/d. Attention should be paid to the monitoring of blood concentration, hemoglobin and reticulocytes.
②Left half of ulcerative colitis: the initial treatment is commonly used mesalazine (5-ASA) enema, 4g per night, if the symptoms are not relieved after 3 to 4 weeks, can be increased to 1 time in the morning and evening. Or add hydrocortisone 100mg/100ml enema, still ineffective or intolerable to patients, can be added or changed to salicylazosulfapyridine (SASP) or mesalazine (5-ASA) orally, first start with a small dose, if tolerated, then gradually increase the amount of, such as salicylazosulfapyridine (SASP) 1g / d or mesalazine (5-ASA) 1 ~ 1.2g / d, and gradually increase to salicylazosulfapyridine ( SASP) 4～6g/d or mesalazine (5-ASA) 4.8g/d. Once the symptoms are relieved, the dosage should be gradually reduced. Maintenance therapy is commonly used 5-ASA enema, 4g per time, once every night or once every 3 nights, or SASP 1～2g/d, 5-ASA 1.2～2.4g/d oral maintenance. Long-term use of SASP should be supplemented with folic acid.
③Right half ulcerative colitis and total colitis: the starting treatment is often used salicylazosulfapyridine (SASP) 4～6g/d or mesalazine 2.0～4.8g/d orally, and mesalazine (5-ASA) enema or corticosteroid enema can be added in the period of acute exacerbation. Once the symptoms subside, the enema should be gradually discontinued and the oral salicylazosulfapyridine (SASP) or mesalazine (5-ASA) should be reduced to a maintenance dose. If it is not effective, it can be changed to prednisone 40～60mg/d orally. Attention to iron supplements, can also be appropriate to add antidiarrheal agents to relieve symptoms. Maintenance therapy with salicylazosulfapyridine (SASP) 1 ~ 2g / d, or mesalazine (5-ASA) 1.2 ~ 2.4g / d.
④Heavy or eruptive ulcerative colitis: this type of patients often have systemic symptoms, easy to complicate the toxic megacolon, intestinal perforation, and need to be hospitalized for observation and treatment. So far the main therapeutic drugs are corticosteroids, severe cases can also drip immunosuppressive drugs or colon resection, the main measures for parenteral nutrition in order to intestinal rest and intravenous corticosteroids. Intravenous nutrition is the same as the conventional method, and corticosteroids can be used as hydrocortisone 100mg intravenous infusion every 8 hours, or prednisolone 30mg intravenous infusion every 12 hours, or methylprednisolone (methylprednisolone) 16-20mg intravenous infusion every 8 hours. The latter two drugs have fewer side effects of sodium retention and potassium loss. When the effect is not obvious, it can be combined with mesalazine (5-ASA) enema or hydrocortisone enema, 2 times / d, can also be combined with antibiotics. For those who are ineffective on corticosteroids, small-dose cyclosporine 2mg/(kg-d) continuous drip can alleviate the condition, avoid emergency colectomy, and reduce the dosage of corticosteroids appropriately. In addition, some people use granulocyte adsorption therapy to achieve better results. Granulocyte adsorption therapy refers to the therapy that removes activated white blood cells, such as granulocytes, monocytes, killer T lymphocytes, etc., from the blood, thus suppressing inflammation. The granulocyte adsorber is a blood filter with small beads filled with cellulose acetate, and when the patient's venous blood flows through it, about 60% of the activated granulocytes and monocytes are adsorbed. The therapy is given once a week for 1h for a course of 5 sessions, and since it is symptomatic, it needs to be maintained on a regular basis. Granulocyte adsorption therapy can be applied to a variety of inflammatory disorders, and its efficiency is 58.5%, higher than the efficacy of corticosteroids 44.2%, and the incidence of adverse effects is only 8.5%, compared with 42.9% for corticosteroids.
⑤Chronic active ulcerative colitis: some patients on salicylazosulfapyridine (SASP), mesalazine (5-ASA), corticosteroids are ineffective, but are unwilling to surgical treatment, the available azathioprine treatment, starting from 50mg/d, gradually increase the amount of the largest amount of 2mg/(kg-d). Although the effective rate of 60% ~ 70%, but the onset of effect takes 3 ~ 6 months, therefore, often in the early stages of treatment need to be maintained with prednisone treatment for at least 2 months before reducing the amount. If the use of mercaptopurine (6-mercaptopurine) or azathioprine is still ineffective after 6 months, it can be changed to methotrexate (methotrexate) 2.5mg/week orally, and then gradually increase the dosage to 10-15mg/week or 25mg/week intramuscular injection. It takes 8 to 10 weeks to see the effect.
2. Surgical treatment Most of the ulcerative colitis received good results by internal medicine, but still 20% to 30% of cases need surgical treatment, resection of diseased intestinal segments and obtain a radical cure. Indications for surgery include:
1) ineffective medical treatment, long-term persistence or recurrent episodes, poor nutritional status, loss of labor, and children's growth and development are seriously affected.
②Colonic fibrous scarring stenosis causing obstruction or loss of function and persistent diarrhea.
③Those who develop or may develop cancer.
④Those who have a violent attack of UC or toxic megacolon that is ineffective after a short period (2-3 days) of medical treatment.
⑤ Those with acute complications, such as perforated or about to be perforated colon and massive blood in stool.
6) Those with extra-intestinal complications, especially arthritis that keeps getting worse.
Over the past 10 years, due to the continuous development and improvement of surgical techniques and equipment, especially the widespread use of laparoscopy and anastomosis, there has been a greater development of surgical treatment, more updates in the concept of treatment, continuous improvement of postoperative function, and improvement of the patient's quality of life. Surgical modalities currently include: ileostomy, colostomy; total resection of the colon, ileorectal anastomosis; total resection of the colorectum, ileostomy; total resection of the colorectum, ileoanal anastomosis. However, the preoperative condition should be fully estimated, the scope of the lesion is clear, reasonable choice of surgical methods.
(1) ileocolostomy: mainly used to treat toxic megacolon, the general situation is very poor, can not tolerate intestinal resection cases. Simple ileocolostomy makes the dilated colon decompression, to wait for the condition to improve after the second stage of intestinal resection. But toxic megacolon intestinal wall is fragile, suture is extremely difficult, so recently the operation is mostly replaced by one-stage intestinal resection.
(2)Total colectomy and ileorectal anastomosis: This surgery is suitable for those who have not found any lesions in the rectum, and it is easy to operate, with good postoperative defecation function, and it is the ileal pouch anastomosis. It is the only procedure that can avoid permanent ileostomy before the introduction of ileac pouch-anal anastomosis (IPAA). However, there is a possibility of disease recurrence or even cancer in the preserved rectum, so frequent follow-up endoscopy is required. Currently, ileorectal anastomosis is less commonly used in clinical practice.
(3) Total proctocolectomy with ileostomy: This is the most thorough and traditional surgery. After removing all the intestinal tubes with lesions, although there is no worry about recurrence of lesions and cancer, there are many problems such as difficulty in handling feces and fecal bags, which will bring long-term life and mental burden to the patients.
(4)IPAA: In recent years, it has been widely used in the treatment of UC, familial polyposis and certain benign rectal diseases, and is a more ideal surgery.IPAA surgery is based on the resection of all the diseased rectal mucosa and colon to prevent recurrence of the disease and carcinoma, and the anastomosis of ileal pouch and anal canal by pulling out the ileal pouch through the rectal musculosheath to preserve the anal sphincter and the function of self-manufactured fecal evacuation. The creation of an intrapelvic storage pouch is a great advancement in direct ileoanal anastomosis and greatly reduces the number of bowel movements, thus replacing direct ileoanal anastomosis.
EGF step-by-step immune reorganization therapy, that is, biology, molecular genetics, modern immunology as the theoretical basis, according to the "step-by-step treatment" mainstream treatment strategy, in the international latest ultrasound electronic colonoscopy high-definition visualization, the ulcer mucosa target, millimeters of point-shot treatment. Scientifically addressing the effects of genetics, environment, intestinal microorganisms, flora, immunity and other factors on inflammatory bowel disease, the treatment utilizes the biological effects of EGF epidermal growth factor and EGF receptor (EGFR) with high affinity to strongly antagonize and block the biological activity of TNF-a, stimulate the mitotic activity and differentiation of cells, and promote the rapid proliferation and repair of epithelial cells. The activation of immune reconstitution and other multi-means intervention strategies are actively used to rebuild the healthy barrier of intestinal mucosal tissues and achieve the purpose of effectively alleviating the disease, preventing cancer and improving the quality of life of patients.